“The workforce is changing…We know that just by going into work every day.” For our fourth macro trend in nursing
, our Chief Nurse, Anne Dabrow Woods DNP RN CRNP ANP-BC AGACNP-BC FAAN, surveys the ways in which the nursing workforce is evolving and adapting. From more men entering the profession, to more nurses with a wider range of specialties, to nurses staying in practice longer, the nursing population is not what is used to be.
Review our handy infographic below to discover the six ways the nursing workforce is changing.
Don’t forget to bookmark our blog and to keep an eye out for the final two trends in nursing. To see Woods’ full Macro Trends in Nursing 2016 presentation, go to the Lippincott NursingCenter YouTube channel
Add this first infographic to your website by copying and pasting the following embed code:
|<a href="http://www.nursingcenter.com/ncblog/january-2017/the-nursing-workforce-is-changing-macro-trends-in"><img src="http://www.nursingcenter.com/getattachment/NCBlog/January-2017/the-nursing-workforce-is-changing-macro-trends-in/the-nursing-workforce-is-changing-infographic.png.aspx?width=300&height=750></a>
<p>Macro Trends in Nursing 2016:<a href="http://www.nursingcenter.com/ncblog/january-2017/the-nursing-workforce-is-changing-macro-trends-in"> The Nursing Workforce is Changing </a> By Lippincott NursingCenter</p>
Posted: 1/13/2017 9:36:37 AM
| with 0 comments
With its 11th edition, we celebrate the 50th anniversary of the Textbook of Basic Nursing
, a step-by-step
comprehensive text that walks LPN/LVN nursing students through basic skills, procedures, concepts, and clinical applications. Based on the NCLEX-PN framework, this engaging text introduced critical thinking to nursing students for the past 50 years thanks to its two authors, Caroline Rosdahl RN, BSN, MA and Mary Kowalski RN, BA, BSN, MSN . Both Rosdahl and Kowalski have been major contributors to the nursing industry since the beginning of their careers. They’ve witnessed first-hand how nursing education has grown and evolved, and they’ve been able to translate these changes into meaningful educational tools for their readers.
During Rosdahl’s time in graduate school, she was approached by someone looking to set up a nursing school and began to write behavioral objectives for them. Rosdahl encountered some push-back from her colleagues, who considered nursing to be “too emotional and too psychological” to have objectives, but she wrote them anyway. After people saw her objectives, she got requests for her syllabi, which led Lippincott to approach her in 1967 to join the textbook’s 2nd edition, which now includes behavioral objectives in every chapter. “I felt I had something unique to offer that hadn’t been done in nursing before,” says Rosdahl. Kowalski joined the textbook as a consultant for its 6th edition, and then became co-author on its 8th edition, which published in 2002. She graduated from nursing school in 1975 and started as a nurse’s aide. When she returned to nursing school, she really enjoyed writing and reading, which translated to her work on the textbook. “I got to learn all of the updated materials, and I’ve enjoyed making sure the students have the information they need. I was an instructor for 25 years, and I really enjoy working with the nursing students,” Kowalski says.
“It’s amazing how many things have changed,” since she started writing for the textbook states Rosdahl. “From government regulations to procedures to equipment,” it’s been a challenge to ensure the textbook stays current she says, but “it is rewarding to see it in print and to see people use it in practice. To think I’ve been around so long is quite amazing.” Over the past 50 years, both Rosdahl and Kowalski have seen the role of the nurse and the technology they use evolve and become more complicated to manage. Rosdahl explains a new challenge today that nurses face is that “patients are sicker and there’s so much more equipment, there’s so many medications and treatments, that it’s not like nursing used to be.” If a patient is in a hospital today, “they have to be really critical, otherwise, they get sent home, and the nurse is expected to be able to do all of this, while also being expect to specialize. If you want to work in an ICU, you need extra training. Back in the day, I could float and work everywhere in a hospital, now a nurse can hardly go from one department to another. It’s so much more complicated.” Kowalski remembers when she started “we didn’t have I.V. pumps that could count the drips for you automatically and have an alarm go off. You had to actually count your drips from the intravenous line so you’d know you had it at the right speed. Otherwise, you’d overflow your patient or give them too much fluid or too little.” When she started in 1975, emergency rooms were just starting to use CPR and triage. “If you go to an ER now, these [nurses] are actually trained to work in an emergency room as a specialty. Now, there’s a whole training shift for acute care nursing.”
With all of the new training initiatives that have occurred, along with new technology being utilized to educate nurses, Kowalski urges that “machines go wrong and students don’t remember to check the machines. You have to calibrate your machines.” For instance, to put the wrong size tubing in the machine could result in the death of a patient. “We depend on the machines and not on the actual human being, but [patients] don’t push the call button because they want their machine adjusted. They push the call button because they want a person.” Rosdahl explains that when she started, nurses learned by clinical experience. They would be in the hospital, taking care of patients and learning on the job, “which was admittedly a little haphazard,” but they were getting experience with patients. “Now, so much of the education is in the laboratory with simulation. There are actually programs without any clinical experience, and that to me, is really scary because the kids get out without any idea on how to relate to a patient.” Today, students enter the workforce and experience a “culture shock,” where they are not used to working weekends, long shift hours, and interacting with patients.
A good change that has occurred, however, is that “there are lots of resources on the internet, which is great and helpful to the students. But sometimes, they are not accurate and you have to really be careful” of your sources, explains Rosdahl. We need to “remind the kids that the internet is not the bible,” she stresses. Kowalski agrees and is concerned about “how much time students are using to look things up” online. “When we were doing the book and editors told us ‘let’s take this part out and put it online,’ there are still a lot of students that actually need it in the book, I think. But, everything is going online, so [the editors and publishers] need to define where students will get their information, whether it’s an online chapter or in the actual book.” Regardless of where they do decide to find their information, however, the source of the information is still the most important thing. Students can value authoritative, credible resources, like the Textbook of Basic Nursing.
For their 50th anniversary edition, Rosdahl and Kowalski have put special attention and time into the textbook. Kowalski really enjoys chapter 13 on “Older Adults and Aging,” which goes over the concept of the aging process and the concept of the paradigm shift in aging. “I had to research the definition of aging, and I discovered there is no real definition,” she says. “Aging used to be 65, but now 85 is really considered ‘older.’” With nurses now working past 65 and a new generation of nurses coming in, chapter 13 goes over the special considerations of an aging nursing workforce. Rosdahl’s favorite section of the textbook is on psychiatry, which is her specialty. She also is happy that two to three editions ago, the textbook began to include colored illustrations, “which really make a difference,” along with the teaching ancillaries. And to top it all off, Rosdahl is excited that there is now an Indonesian translation of the textbook.
For new nurses starting out, the authors have some advice. Rosdahl advises that “all education is aimed at teaching how to learn. You can’t teach [students] all of the material, so nurses need to know that they don’t know everything, and they have to use references, other nurses, and find out what they don’t know about an individual patient. They need to know what they don’t know.” Kowalski stresses that the first year of their career is the most critical. “They need to know they will be scared to death. They don’t know what to do and they will say they didn’t learn anything in nursing school…but in the next three months things will become calmer for them in the real world. Then by the sixth month after they graduated, they will think ‘oh, I can do this,” but then will become cocky. They start taking shortcuts, which is when the most errors occur – it’s between the sixth month post-graduation to the ninth month.” The last three months of that first year, she says, are where you really understand what they’re doing as a nurse.
As Rosdahl and Kowalski turn their attention to the next 50 years to come, they see a bright future for nursing. “We are going to have more men in nursing,” predicts Rosdahl, and “with that, comes a difference in salaries, which will increase.” She also believes that nursing will continue to grow more complicated over time, and “we’re going to need more nurses, we are going to need more specialized nurses, and we are going to need more nurses in the community. People are sent home early and they will need to be cared for.” Kowalski predicts there will be more machines and computers in nursing than there are today. The information will be more automated, she explains, and that it is “both good and bad. The information is numbers, which doesn’t tell you if your patient is crashing.” Nurses will continue to need to learn how to interpret these numbers and the machines to benefit their patients.
To learn more from these authors, visit the Textbook of Basic Nursing
Posted: 1/6/2017 9:20:02 AM
| with 2 comments
Happy New Year! Here’s the list of nursing recognition days, weeks, and months for 2017*.
Know of others? Please leave a comment or email firstname.lastname@example.org
*Dates and links will be updated as they become available.
Let us know how you will celebrate or what plans you have to recognize your colleagues. Leave a comment or email us at email@example.com
Have a great year!
Posted: 1/4/2017 3:13:05 PM
Lisa Bonsall, MSN, RN, CRNP
| with 1 comments
Mastering hemodynamics can be tricky, but the first step is understanding the terminology. Let’s take a look at cardiac output and cardiac index – how to calculate them and why they’re important.
Cardiac Output (CO)
is the volume of blood the heart pumps per minute. Cardiac output is calculated by multiplying the stroke volume by the heart rate. Stroke volume
is determined by preload
, contractility, and afterload
. The normal range for cardiac output is about 4 to 8 L/min, but it can vary depending on the body’s metabolic needs. Cardiac output is important because it predicts oxygen delivery to cells.
Here’s an example:
If a patient's stroke volume is 75 mL with each contraction and his heart rate is 60 beats/minute, his cardiac output is 4,500 mL/minute (or 4.5 L/minute).
Cardiac Index (CI)
The cardiac index
is an assessment of the cardiac output value based on the patient’s size. To find the cardiac index, divide the cardiac output by the person’s body surface area (BSA). The normal range for CI is 2.5 to 4 L/min/m2
Here’s an example of how to calculate the cardiac index:
If a patient’s cardiac output is 4.5 L/minute and his BSA is 1.25 m2
, his CI would be 3.6 L/min/m2
. If another patient has a cardiac output of 4.5 L/minute, but he has a BSA of 2.5 m2
, his CI would be 1.8 L/min/m2
Both cardiac output and cardiac index are important to let us know if a patient’s heart is pumping enough blood and delivering enough oxygen to cells. We also use CO and CI values to manage certain drug therapy, such as inotropics and vasopressors.
It’s hard to believe that 2016 is coming to a close. We’ve had some amazing experiences at nursing conferences and events
Our senior publisher, Bob Maroldo, and I attended the NSNA Annual Conventio
n in the spring in Orlando, where I met many excited and eager nursing students about to start their careers. I also had the chance to go to Nursing2016 Symposium and National Conference for Nurse Practitioners (NCNP)
in Orlando with our clinical editor, Lisa Bonsall, MSN, RN, CRNP. You can see a highlights video of all the fun we had on our Lippincott YouTube Channel
Lisa also attended the NCNP’s fall conference
in Chicago with our senior editor, Kim Fryling-Resare, as well as Nursing Management Congress (NMC) 2016
in Las Vegas.
Our team had a blast meeting and greeting nurses from all different practice areas and specialties -- we can’t wait for the upcoming nursing events in 2017! We compiled a variety of nursing conferences and events happening next year and here are a few to look out for.
Nursing Events 2017
• National Conference for Nurse Practitioners: The Conference for Primary and Acute Care Clinicians
, April 19-22nd, Nashville, TN.
• Nursing Management Congress 2017
, October 2-6th, Las Vegas, NV.
•National Conference for Nurse Practitioners: The Conference for Primary and Acute Care Clinicians
, October 9-12th, Las Vegas, NV.
To see all the nursing conferences in 2017, visit our Nursing Events Calendar
Which conferences are you planning to attend?
Posted: 12/8/2016 8:02:11 AM
| with 1 comments
Categories: Continuing Education
With the end of 2016 quickly approaching, it’s important to look ahead to the future trends happening in the nursing profession. More and more, nurses are going back to school to earn higher degrees, but why? "Life-long learning keeps nurses up-to-date on the advances in practice and can help them critically think more thoroughly because they have more evidence and information to inform their practice decisions,” explains our Chief Nurse, Anne Dabrow Woods DNP RN CRNP ANP-BC AGACNP-BC FAAN.
Whether you’re a nurse with a diploma or associate’s degree contemplating achieving your BSN
, or you’re looking to pursue an advanced degree in nursing
, you’re not alone. According to a 2014 survey by the American Association of Colleges of Nursing (AACN)
, there’s been a “4.2% increase in students in entry-level baccalaureate programs (BSN) and a 10.4% increase in ‘RN-to-BSN’ programs for registered nurses looking to build on their initial education at the associate degree or diploma level. In graduate schools, student enrollment increased by 6.6% in master’s programs and by 3.2% and 26.2% in research-focused and practice-focused doctoral programs, respectively.”
With this new shift to lifelong learning in nursing, educators are adapting the way to they teach their students. “When we were [originally] taught how to educate students,” Woods says, “we were taught to sit them in a classroom and to lecture to them. That is not reality anymore today. What we’ve seen is a whole flip of the classroom so that the students or nurses…read, learn, and then come together and they discuss how to actually apply the principles that they’ve learned. That’s called the ‘flipped classroom,’ and that is what we are going to be using from now on.”
To discover more about the flipped classroom and other changes in lifelong learning in nursing, utilize this handy infographic.
Remember to bookmark our blog and look out for the next three trends in nursing. Our Chief Nurse also gave a presentation on the six key trends in nursing
. To see Woods’ full Macro Trends in Nursing 2016 presentation, go to the Lippincott NursingCenter YouTube channel
Add this first infographic to your website by copying and pasting the following embed code:
|<a href="http://www.nursingcenter.com/ncblog/november-2016/lifelong-learning-in-nursing-macro-trends-in-nursi"><img src="http://www.nursingcenter.com/getattachment/NCBlog/November-2016/lifelong-learning-in-nursing-macro-trends-in-nursi/macrotrend-3-infographic_lifelong-learning-in-nursing.png.aspx?width=300&height=750></a>
<p>Macro Trends in Nursing 2016:<a href="http://www.nursingcenter.com/ncblog/november-2016/lifelong-learning-in-nursing-macro-trends-in-nursi"> Lifelong Learning in Nursing </a> By Lippincott NursingCenter</p>
Posted: 11/28/2016 8:34:54 AM
| with 1 comments
Nurse leaders + Las Vegas + a Presidential election = a busy conference week! Whew…it certainly was an eventful week as nurse leaders from around the world got together in Las Vegas for Nursing Management Congress 2016!
For two days, preconference workshops were in action. The New Manager Intensive
provided fundamentals for success for those new to the role, including calculations – staffing, supplies, and equipment – to effectively and safely run a unit. In addition, new managers brushed up on relationship and communication skills, as well as handling the pressures of leadership through a period of health care reform. The Experienced Nurse Leader Intensive
covered topics related to the business of health care, such as aligning with organizational goals, team development, and improving performance. Other sessions during these two days included a Certification Prep Course, Creating a World-Class Culture,
and Improving the Patient Experience.
An opening session to remember
This was my first real exposure to Zubin Damania, MD, aka ZDoggMD
, and I am now a big fan! His humor, talent, and passion for improving the patient experience were inspiring. He encouraged us to “reshuffle our deck” and embrace a new era of health care – Health 3.0 – re-personalized medicine with a focus on building relationships. Here’s a brief video clip from his keynote address:
You can find ZDoggMD on YouTube, Facebook
, and twitter
. His “membership-based primary care and wellness ecosystem”, Turntable Health
, is truly breaking down barriers.
So much learning
While I’ve never held a role in nursing management, the knowledge and advice from the experts at NMC are beneficial to all nurses. Here are some of the pearls and tips I learned:
“To be a successful leader, you must be flexible and move quickly in decision making.’”
Jeffrey Doucette, DNP, RN, FACHE, CENP, LNHA
“Until you change people’s minds about their work habits, they’re not going to change their work habits.”
Changing the Culture of Fatigue: A Nurse AND Patient Safety Problem
Mary Lawson Carney, DNP, RN-BC, CCRN, CNE
“Understanding quality across the continuum will lead to improved outcomes across the continuum.”
Reducing Readmissions Across the Care Continuum
Leonard L. Parisi, RN, MA, CPHG, FNAHQ
“Nurses should prepare for the future by keeping their eyes on how nursing care helps patients become and stay healthy and allows the health care system to work smoothly.”
Nursing Workforce Predictions: What’s Really Happening?
Sean Clarke, PhD, RN, FAAN
“It’s the simple solutions that get us where we need to be.”
Getting the Most from People Around You
Andrea Mazzoccoli, MSN, MBA, PhD, FAAN
“The curse of knowledge…We forget what it was like to not know what we know now.”
Talkin’ Bout My Generation: Generations in the Workplace should be Your GREATEST Strength, Not Your Biggest Headache!
As next year’s planning gets underway, we invite you to look at our 2016 NMC photo album
, see social media highlights
, and submit an abstract!
See you next year!
Last year, during the holiday season, we shared Three inspirational gifts for nurses
. This year, we’ve got some more gift ideas to share with you! Explore the products below and consider which nurse you’d like to surprise this year with a special gift. You may even want to pick up one of these for yourself, or leave some hints for your family and friends!
Offering life- and career-changing moments in nurses’ lives, the 80 true stories in Reflections on Nursing
, from the American Journal of Nursing,
reveal nursing at its most demanding and fulfilling. These inspiring, true stories—written by nurses in numerous care settings—show nursing as both professional and life experience, and often, as an inspired journey. Here’s a look at some of the stories that caught my eye: In the Hand of Dad: Preemie's struggle becomes one nurse's journey with a father;
At Her Mercy: A nursing instructor finds herself in the hands of a challenging former student; and
Nurse, Heal Thyself: Walking in the patient's shoes.
I picked up my copy of the Inspired Nurses Calendar
earlier this month and have already put it to use! This is the gift that keeps on giving all year! Each month showcases a different story from a nurse that demonstrates our hard work and dedication. You will be reminded daily of what it means to be a nurse. By reading these stories, such as that of a NICU mom who went on to become a NICU nurse or a church missionary nurse now pursuing her DNP, you’re sure to be reminded of your own journey in nursing and your past experiences, and probably ponder, as I do, what the future holds.
Based on the same content used by hospitals and brought to you by the most trusted source in nursing, the Lippincott Advisor
app is an expanding collection of over 2,000 evidence-based, clinical decision support entries on diseases, treatments, signs and symptoms, and diagnostic tests that are updated quarterly. You can take all that you learned in school with you and be able to make clinical decisions at the bedside – safely and confidently.
Have a wonderful holiday season!
Posted: 11/21/2016 8:43:54 PM
Lisa Bonsall, MSN, RN, CRNP
| with 1 comments
This week has demonstrated that the political climate in the United States is not fixed in a stationary position but, is dynamic. Many of you will be asking yourselves what does this mean for healthcare reform, the Affordable Care Act, and for nurses and advanced practice nurses (APNs) in the United States. The bottom line is we just don't know. However, one thing we are sure of is, healthcare needs to be reformed and we must be present at the table when options are being discussed.
So, what can you do?
First, you need to understand your scope of practice and if you live in a state with restricted practice, you need to continue to lobby your congressmen and senators about the value nurses and APNs bring to patients and healthcare delivery.
Secondly, be the voice of reason. There are many things about the Affordable Care Act that have improved access to care and quality of care; we must be able to articulate why those things are important and why they need to stay from a cost-benefit and cost-effectiveness perspective.
Thirdly, educate our healthcare colleagues and healthcare consumers about who we are as a profession and why having a nurse and an APN as part of the healthcare team improves quality, patient-centered care.
And finally, remember our history and the great strides we have made as a profession. The profession of nursing is growing and changing based on the needs of those we serve. We are all Americans and our goal is to improve patient care and outcomes regardless of who is in power.
In conclusion; step up, have a voice, be able to articulate the message, and speak from a position of knowing what you do in practice does make a difference.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN
Health Learning, Research & Practice
Posted: 11/11/2016 9:03:04 AM
Lisa Bonsall, MSN, RN, CRNP
| with 1 comments
I stood in the doorway of room 630 and observed her staring out the window, consumed by thought. She was a 20-year old young woman who had been admitted to the medical unit due to gastrointestinal bleeding. I walked into the room, introduced myself and told her that I needed to perform my initial physical assessment. I put on my stethoscope and motioned closer, then she raised her hands and said “Please, don’t.” I stepped back, confused, and informed her that I needed to check on her bleeding and to make sure everything was ok. She shook her head as tears filled her eyes. I asked her why she was crying and she stated “because I don’t feel comfortable having a stranger touch me.” I assured her that I wouldn’t hurt her and after several more minutes of silence she stated, “I was sexually abused as a teenager.” I thanked her for sharing that very personal and painful information and asked how I could make her more comfortable. She was grateful and just asked for more time. It was early in my nursing career, and I didn’t have any specific training or experience dealing with trauma victims.
Traumatic events, such as sexual abuse, domestic violence, elder abuse, and combat trauma, can have serious long-term detrimental effects on the physical, emotional, and mental well-being of an individual. These life events may lead to depression, distrust, smoking, substance abuse, shame, and low self-esteem. Traumatic events can also shape an individual’s comfort level and attitude toward health care.1
Routine preventative health care visits that involve invasive physical exams and close contact with a health care provider could trigger fear and anxiety in the patient.
Trauma-informed care (TIC) is a term that has been used in recent years in a variety of areas, including social services, education, mental health, and corrections to address the needs of people who have experienced traumatic life events. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines trauma-informed care as a methodology to respond to those who are at risk or have experienced trauma.2
There are four essential approaches and six principles of trauma-informed care.
The four essential approaches of trauma-informed care can be found in a program, organization, or system that2
- Realizes the widespread impact of trauma and understands potential paths for recovery.
- Recognizes the signs and symptoms of trauma in clients, families, staff, and others.
- Responds by fully integrating knowledge about trauma into policies, procedures, and practices.
- Seeks to actively resist retraumatization.
The six key principles of trauma-informed care include2
- Safety – make sure your patient and family members feel safe, both physically and psychologically.
- Trustworthiness and transparency – trust between patients, staff, and management is vital in building strong relationships.
- Peer support – identify individuals with similar experiences of trauma helps to create safety, builds trust, enhances collaboration, and promotes recovery and healing.
- Collaboration and mutuality – emphasize that all members of the team, including patients, are equal.
- Empowerment, voice, and choice – identify individual strengths and differences and utilize them as the foundation for recovery and healing. Provide the patient with choices and an opportunity to share in the decision-making process, which results in a sense of control.
- Recognition of cultural, historical, and gender issues – set aside cultural stereotypes and biases.
How do we put these principles into every day practice? For patients who openly share their trauma history, clinicians should be careful when delving into their psychological histories, unless they have specific training in trauma.1
Many patients, however, feel ashamed and are not comfortable exposing their past. Every member of the health care team should be trained on universal trauma precautions, which is the idea that every person potentially has a history of trauma.2
There are several strategies that clinicians can utilize to implement the TIC approach in general patient care. 1
1. Patient-centered communication:
2. Understanding the health effects of trauma:
- Ask every patient what can be done to make them more comfortable during their appointment.
- Before the physical exam, explain what parts of the body will be involved and allow the patient to ask questions.
- Give the patient the option to shift their clothing out of the way instead of putting on a gown.
- Provide a pillow for back support for patients who are anxious in the supine position.
- Offer a mirror to see procedures or examinations that a patient cannot see.
- If a patient seems moderately to highly anxious, offer ways for patients to signal distress either verbally or by raising their hand during a procedure.
3. Multidisciplinary collaboration:
- Understand that poor coping mechanisms, such as smoking, substance abuse, overeating, and high-risk sexual behavior, may be related to trauma history.
- Engage with patients in a collaborative, non-judgmental manner when discussing health behavior change.
- Maintain a list of referral sources across disciplines for patients who disclose a trauma history.
- Keep referral and educational material on trauma available in waiting rooms.
- Engage in inter-professional collaboration to ensure continuity of care.
4. Understanding your own history and reactions:
- Reflect on your own trauma history (if applicable) and how it might influence patient interactions.
- Learn the signs of professional burnout and prioritize good self-care.
- Decide if your organization will screen for current trauma or a history of traumatic events.
- Consider if screenings will be face-to-face or self-reported by the patient.
- Provide all staff with communication skills training about how to discuss a positive trauma screening with a patient.
- Ensure your organization has the resources available to properly care for the patient, or have processes in place to refer patients to other resources.
Unfortunately, traumatic events occur more often in our society than we think. Caring for patients with a history of traumatic life events requires a high level of sensitivity and compassion. Health care organizations can assist their staff in navigating delicate and difficult situations by providing educational training, tools and resources on the trauma-informed care approach.
Resources for Health Care Providers:
Child Welfare Information Gateway
National Council for Behavioral Health
Substance Abuse and Mental Health Services Administration
The Trauma Informed Care Project
Myrna B. Schnur, RN, MSN
Posted: 11/10/2016 2:29:07 AM
Lisa Bonsall, MSN, RN, CRNP
| with 0 comments
Categories: Patient Safety